Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

September 2018

· ISMP Updates List of High-Alert Medications

· ECRI Institute Partnership: Closing the Loop

· More Clinical Decision Support Successes

· Mergers and Patient Safety

ISMP Updates List of High-Alert Medications

ISMP (Institute for Safe Medication Practices) has long been the “go to” resource for information and tools regarding medication safety. One of ISMP’s most valuable medication safety tools is its List of High-Alert Medications. ISMP recently updated that list, based upon review of errors submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), literature review, input from various safety experts, and responses to a survey of readers of ISMP newsletters.

Survey respondents most frequently identified the following medications: anticoagulants, insulin, neuromuscular blocking agents, chemotherapy, opioids, hypertonic sodium chloride injection (concentrations greater than 0.9%), adrenergic agonists, and other concentrated electrolytes.

See ISMP’s newsletter (ISMP 2018) detailing the responses to the survey and the deliberations that went into their update of the list. Several additions were made to the list:

The antithrombotic category was expanded to incorporate the several new direct anticoagulants on the market.
LORazepam was added as a moderate sedating agent and several minimal sedating agents were added to the list for children.

Other changes included:

Narrowing of the hypoglycemic category to just sulfonurea hypoglycemics.
Changing “IV promethazine” to “promethazine by injection”.
IV radiocontrast media was removed from the list

Hospitals and ambulatory sites are required to have lists of high-alert medications (Joint Commission standard). The list of high-alert medications will vary from hospital to hospital, depending upon the pattern of medication use most prevalent at each hospital. For example, the list at a behavioral health facility will likely differ from that at a general hospital, and that at a pediatric hospital will likely be different from both.

Hospitals may well include some drugs not on ISMP’s list. While drugs on the list are usually those frequently prescribed at the hospital, we also caution hospitals to consider putting on the list drugs that may be dangerous and which their staff may be relatively unfamiliar with. For example, we recommend hospitals consider including desmopressin on their list. Particularly since this drug is being prescribed more and more for treatment of nocturia, patients are showing up in the hospital who have been on it at home. Staff are frequently unfamiliar with it and the other medical conditions that led to the hospitalization may render the patient even more vulnerable to the unwanted side effects of desmopressin. We refer you to our Patient Safety Tips of the Week for March 18, 2008 “Is Desmopressin on Your List of Hi Alert Medications?” and October 25, 2016 “Desmopressin Back in the Spotlight” for details.

One surprising finding in the responses to ISMP’s recent survey was that, even though almost all hospitals had a high-alert drug list, only 64% reported that they utilized special precautions to minimize and prevent errors for all of the high-alert medications on their list. The whole point of such a list is not only to alert all staff to the dangers but also to provide guidance about precautions to minimize risk of these agents.

References:

ISMP (Institute for Safe Medication Practices). High-Alert Medication Survey Results Lead to Several Changes for 2018. ISMP Medication Safety Alert! Acute Care Edition 2018; 23(17): August 23, 2018

http://www.ismp.org/resources/high-alert-medication-survey-results-lead-several-changes-2018

ISMP (Institute for Safe Medication Practices). High-Alert Medications in Acute Care Settings. August 23, 2018

http://www.ismp.org/recommendations/high-alert-medications-acute-list

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ECRI Institute Partnership: Closing the Loop

One of our most frequent topics has been communication errors that cause diagnostic errors and delays that may lead to disastrous patient outcomes (see list of columns at the end of today’s column). Recently, there have been several initiatives or studies that have expounded upon this issue.

ECRI Institute partnered with multiple organizations and convened an expert advisory panel to address the issues of errors or delays in diagnosis related to failure to follow up and errors related to changes or discontinuation of medications (ECRI Institute 2018). That Partnership for Health IT Patient Safety identified three key safe practice recommendations:

Develop and apply IT solutions to communicate the right information (including data needed for interpretation) to the right people, at the right time, in the right format
Implement health IT solutions to track key areas
Use health IT to link and acknowledge the review of information and the documentation of the action taken

We hope you’ll access the ECRI Partnership toolkit which also contains an excellent slide presentation. The report and toolkit are very valuable resources that every healthcare organization can benefit from.

Meanwhile, our neighbors to the north have launched a campaign Greg’s Wings, highlighted by the film Falling Through the Cracks: Greg's Story. This is a powerful story of how failures in communication (“no news is good news”) led to diagnostic and therapeutic delays and ultimately the death of a young man. You’ve heard us so many times use the phrase “stories, not statistics” to drive buy-in from healthcare workers in a variety of patient safety issues. This film provides such a story.

One of the salient features in Greg’s Story is faxed referrals to specialists being lost and ignored. We highlighted the surprising continued role faxes play in healthcare and the problems associated with them in our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am”. An editorial in the Canadian press (Picard 2018) notes that, just as in the US, Canadian physicians still rely primarily on fax for communication with other physicians, despite the fact most have electronic medical record systems.

And failures in communication about diagnoses also happen when patients are transferred from one hospital to another. A recent study from University of Minnesota researchers (Usher 2018) looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).

But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).

All these endeavors highlight the need for better communication on multiple levels in the healthcare continuum to reduce diagnostic errors and delays that may lead to adverse patient outcomes.

See also our other columns on communicating significant results:

May 1, 2007 “The Missed Cancer”
February 12, 2008 “More on Tracking Test Results”
October 13, 2009 “Slipping Through the Cracks”
July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results”
March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
March 1, 2011 “Tests Pending at Discharge”
August 21, 2012 “More on Missed Followup of Tests in Hospital”
October 2, 2012 “Test Results: Everyone’s Worst Nightmare”
March 12, 2013 “More on Communicating Test Results”
October 2013 “New AHRQ Toolkit: Improving Your Office Testing Process”
January 2014 “Email Alerts for Pending Test Results”
July 2015 “Technology to Avoid Delays in Follow-up of Significant Results”
November 17, 2015 “Patient Perspectives on Communication of Test Results”
December 20, 2016 “End-of-Rotation Transitions and Mortality”

Some of our prior columns on diagnostic error:

September 28, 2010 “Diagnostic Error”
November 29, 2011 “More on Diagnostic Error”
May 15, 2012 “Diagnostic Error Chapter 3”
May 29, 2008 “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”
August 12, 2008 “Jerome Groopman’s “How Doctors Think”
August 10, 2010 “It’s Not Always About The Evidence”
January 24, 2012 “Patient Safety in Ambulatory Care”
October 9, 2012 “Call for Focus on Diagnostic Errors”
March 2013 “Diagnostic Error in Primary Care”
May 2013 “Scope and Consequences of Diagnostic Errors”
August 2013 “Clinical Intuition”
January 2014 “Trigger Tools to Prevent Diagnostic Delays”
January 14, 2014 “Diagnostic Error: Salient Distracting Features”
May 2014 “Frequency of Diagnostic Errors in Outpatients”
June 24, 2014 “Lessons from the General Motors Recall Analysis”
November 25, 2014 “Misdiagnosis Due to Lab Error”
April 21, 2015 “Slip and Capture Errors”

And our review of Malcolm Gladwell’s “Blink” in our Patient Safety Library

References:

ECRI Institute. ECRI Institute's Partnership for Health IT Patient Safety Releases New Recommendations to Avoid Testing and Medication Mix-ups. Publicly available report offers important tools and guidance for all healthcare systems. ECRI Institute 2018; Press release July 26, 2018

https://www.prnewswire.com/news-releases/ecri-institutes-partnership-for-health-it-patient-safety-releases-new-recommendations-to-avoid-testing-and-medication-mix-ups-300687233.html

Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT. ECRI Institute 2018

https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_Loop_Toolkit.pdf

Greg’s Wings

http://gregswings.ca/

Film: Falling Through the Cracks: Greg’s Story

http://gregswings.ca/fttc-gregsstory/

Picard A. Why are fax machines still the norm in 21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11, 2018

https://www.theglobeandmail.com/opinion/article-why-are-fax-machines-still-the-norm-in-21st-century-health-care/

Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. Journal of General Internal Medicine 2018; 33(9): 1447-1453

https://link.springer.com/article/10.1007/s11606-018-4491-x

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More Clinical Decision Support Successes

It seems we’ve done all too many columns on the unintended consequences of healthcare IT. So we’re happy to highlight this month some success stories for clinical decision support systems (CDS).

Cedars-Sinai Medical Center integrated select recommendations from the Choosing Wisely campaign as CDS alerts into their EHR. This included many alert-based CDS interventions, both inpatient and ambulatory. Providers, when presented with an alert, had the option to cancel, change, or justify the order, They analyzed the impact of these CDS alerts on inpatient encounters (Heekin 2018). The researchers found that encounters in which providers adhered to all alerts had significantly lower total costs, shorter lengths of stay, a lower probability of 30-day readmissions, and a lower probability of complications compared with nonadherent encounters. Full adherence to Choosing Wisely alerts was associated with savings of $944 from a median encounter cost of $12,940.

Another recent study (Wachsberg 2018) demonstrated that an educational intervention, combined with real-time clinical decision support (CDS), reduced blood utilization among hospitalized solid tumor cancer patients without adversely affecting outcomes. The odds of receiving a transfusion were cut by almost half in the postintervention cohort. There were no significant differences in readmission, outpatient transfusion within seven days of discharge, or inpatient mortality. Patients in the postintervention cohort also had lower odds of ICU transfer (OR = 0.29).

And another study in a large academic medical center (Eaton 2018) showed a mixed impact of nonintrusive clinical decision support systems on laboratory test utilization, reminding us to focus on areas where a positive impact is seen and avoid unnecessary alerts that don’t change outcomes. The study focused on CDS for red blood cell folate, hepatitis C virus viral loads and genotypes, and (blood) type and screens. Appropriate indications for these labs were incorporated into text that accompanied the laboratory orders in the hospital's EHR. There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions after the CDS was implemented. But there was no significant change in type and screen orders or folate orders. The authors stress that nonintrusive CDS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.

The last point is very important. Avoiding alert fatigue is critical in any clinical decision support program. We stress to hospitals that they need to have an interdisciplinary group that works with their IT staff to evaluate the impact of every new CDS rule implemented. That means looking to see what the adherence/override rate is for each alert and whether the alert results in the desired change in ordering.

These three studies, however, clearly show that careful planning, implementation, and evaluation of clinical decision support tools can be beneficial to patient care and can be done in a manner that is nonintrusive.

See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:

June 19, 2007 “Unintended Consequences of Technological Solutions”
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
August 26, 2008 “Pattern Recognition and CPOE”
September 9, 2008 “Less is More….and Do You Really Need that Decimal?”
December 16, 2008 “Joint Commission Sentinel Event Alert on Hazards of Healthcare IT”
February 2009 “Healthcare IT The Good and The Bad”
March 3, 2009 “Overriding Alerts…Like Surfin’ the Web”
October 2009 “A Cautious View on CPOE”
November 24, 2009 “Another Rough Month for Healthcare IT
April 20, 2010 “HIT’s Limited Impact on Quality To Date”
March 22, 2011 “An EMR Feature Detrimental to Teamwork and Patient Safety”
January 24, 2012 “Patient Safety in Ambulatory Care”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”
July 17, 2012 “More on Wrong-Patient CPOE”
January 2013 “More IT Unintended Consequences”
April 30, 2013 “Photographic Identification to Prevent Errors”
October 8, 2013 “EMR Problems in the ED”
March 11, 2014 “We Miss the Graphic Flowchart!”
October 2014 “Ebola Exposes Fundamental Flaw”
January 2015 “Beneficial Effect of EMR on Patient Safety”
March 2015 “CPOE Fails to Catch Prescribing Errors”
March 31, 2015 “Clinical Decision Support for Pneumonia”
August 2015 “Newborn Name Confusion”
December 2015 “Opioid Alert Fatigue”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
February 9, 2016 “It was just a matter of time…”
April 5, 2016 “Workarounds Overriding Safety”
May 2016 “Name Confusion in the Pharmacy”
May 3, 2016 “Clinical Decision Support Malfunction”
May 24, 2016 “Texting Orders – Is It Really Safe?”
August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”
November 22, 2016 “Leapfrog, Picklists, and Healthcare IT Vulnerabilities”
January 2017 “Joint Commission Thinks Twice About Texting Orders”
February 28, 2017 “The Copy and Paste ETTO”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
April 2017 “How Much Time Do We Actually Spend on the EMR?”
June 27, 2017 “Texting – We Told You So!”
August 1, 2017 “Progress on Wrong Patient Orders”
January 2018 “Can We Improve Barcoding?”
January 16, 2018 “Just the Fax, Ma’am”
January 30, 2018 “Texting Errors Revealed”
June 19, 2018 “More EHR-Related Problems”

References:

Heekin AM, Kontor J, Sax HC, et al. Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes. Am J Manag Care 2018; 24(8): 361-366

https://www.ajmc.com/journals/issue/2018/2018-vol24-n8/choosing-wisely-clinical-decision-support-adherence-and-associated-inpatient-outcomes

Wachsberg KN, O'Leary KJ, Buck R, et al. Impact of Real-Time Clinical Decision Support on Blood Utilization and Outcomes in Hospitalized Patients with Solid Tumor Cancer. The Joint Commission Journal on Quality and Patient Safety 2018; Published online: August 17, 2018

https://www.jointcommissionjournal.com/article/S1553-7250(17)30485-3/fulltext

Eaton KP, Chida N, Apfel A, et al. Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre. Journal of Evaluation in Clinical Practice 2018; 24(3): 474-479 First Published: 15 February 2018

https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12890

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Mergers and Patient Safety

In multiple presentations on healthcare policy (outside of our patient safety activities) we have discussed the impact of mergers and acquisitions in healthcare. Having participated directly or indirectly in several mergers, we’ve focused primarily on the financial implications.

The American Hospital Association (AHA 2017) released a report in 2017 (Noether 2017) touting that:

Mergers decrease costs due to economies of scale, reduced costs of capital and clinical standardization among other efficiencies
Mergers have the potential to drive quality improvements through standardization of clinical protocols and investments to upgrade facilities and services at acquired hospitals.
Mergers typically expand the scope of services available to patients, and build upon existing institutional strengths to provide more comprehensive and efficient care.

Call us skeptics. While every merger promises the community incredible financial benefit, few deliver on those promises. Theoretically, mergers should produce much savings by eliminating duplication. But, in reality, such mergers usually result in putting negotiating clout in one system and eventually rising healthcare costs for the community.

A number of years ago we participated in a panel discussion with Alan Sager, Ph.D., from Boston University School of Public Health, who had done extensive research on the community impact of hospital closures. His research showed that hospital closings have repeatedly failed to cut costs, and can even result in increased costs. Moreover, hospital closings have harmed access to care—particularly in underserved areas and communities of color (Sager 2006).

But until now there has been little attention to the patient safety repercussions of hospital mergers. Haas and colleagues (Haas 2018) recently published a Viewpoint in JAMA, highlighting several key challenges and barriers that may interfere with clinical care following mergers.

The authors identified 3 key risks to patient care resulting from mergers:

New patient populations
Unfamiliar infrastructure
New settings for physicians

Post-merger, patients may be cared for by clinicians and staff who have little existing knowledge about them. Changes in supplies, equipment, formularies, protocols, and information systems also lead to unfamiliarity that may adversely impact patient care. And physicians, especially specialists, may now be required to travel to new settings where they may be unfamiliar with infrastructure, processes, teams, and clinical cultures that may differ significantly from one organization to the other(s).

Importantly, in collaboration with their Ariadne Labs, they make available for free a guide and patient safety toolkit to help with clinical planning between institutions prior to mergers. It also includes a checklist for developing a joint clinical integration council.

Mergers are not easy on clinicians and healthcare staff and ultimately may jeopardize patient safety. These resources are extremely valuable for any organizations considering merger and need to be tapped very early in any discussions about merger.

References:

AHA (American Hospital Association). New Research Finds Hospital Mergers Drive High-Value, High-Performing Health Care. AHA Press Release 2017; January 25, 2017

https://www.aha.org/press-releases/2017-01-25-new-research-finds-hospital-mergers-drive-high-value-high-performing

Noether M, May S. Hospital Merger Benefits: Views from Hospital Leaders and Econometric Analysis. Charles River Associates 2017; January 2017

https://www.aha.org/system/files/2018-04/Hospital-Merger-Full-Report-FINAL-1.pdf

Sager A, Socolar D. Closing Hospitals in New York State Won’t Save Money But Will Harm Access to Health Care. A Short Report Prepared for The Committee of Interns and Residents New York City. 20 November 2006

https://www.bu.edu/sph/files/2015/05/Sager-Hospital-Closings-Short-Report-20Nov06.pdf

Haas S, Gawande A, Reynolds ME. The Risks to Patient Safety From Health System Expansions. JAMA 2018; 319(17): 1765-1766

https://jamanetwork.com/journals/jama/article-abstract/2678285

Ariadne Labs. Patient safety toolkit for system expansion.

https://www.ariadnelabs.org/safe-expansion/

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